1
|
Robateau Z, Lin V, Wahlster S. Acute Respiratory Failure in Severe Acute Brain Injury. Crit Care Clin 2024; 40:367-390. [PMID: 38432701 DOI: 10.1016/j.ccc.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Acute respiratory failure is commonly encountered in severe acute brain injury due to a multitude of factors related to the sequelae of the primary injury. The interaction between pulmonary and neurologic systems in this population is complex, often with competing priorities. Many treatment modalities for acute respiratory failure can result in deleterious effects on cerebral physiology, and secondary brain injury due to elevations in intracranial pressure or impaired cerebral perfusion. High-quality literature is lacking to guide clinical decision-making in this population, and deliberate considerations of individual patient factors must be considered to optimize each patient's care.
Collapse
Affiliation(s)
- Zachary Robateau
- Department of Neurology, University of Washington, Seattle, USA.
| | - Victor Lin
- Department of Neurology, University of Washington, Seattle, USA
| | - Sarah Wahlster
- Department of Neurology, University of Washington, Seattle, USA; Department of Neurological Surgery, University of Washington, Seattle, USA; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA
| |
Collapse
|
2
|
Kim JG, Ahn C, Kim W, Lim TH, Jang BH, Cho Y, Shin H, Lee H, Lee J, Choi KS, Na MK, Kwon SM. Comparison of video laryngoscopy with direct laryngoscopy for intubation success in critically ill patients: a systematic review and Bayesian network meta-analysis. Front Med (Lausanne) 2023; 10:1193514. [PMID: 37358992 PMCID: PMC10289197 DOI: 10.3389/fmed.2023.1193514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/22/2023] [Indexed: 06/28/2023] Open
Abstract
Introduction This review compares the efficacy of video laryngoscopy (VL) with direct laryngoscopy (DL) for successful tracheal intubation in critically ill or emergency-care patients. Methods We searched the MEDLINE, Embase, and Cochrane Library databases for randomized controlled trials (RCTs) that compared one or more video laryngoscopes to DL. Sensitivity analysis, subgroup analysis, and network meta-analysis were used to investigate factors potentially influencing the efficacy of VL. The primary outcome was the success rate of first-attempt intubation. Results This meta-analysis included 4244 patients from 22 RCTs. After sensitivity analysis, the pooled analysis revealed no significant difference in the success rate between VL and DL (VL vs. DL, 77.3% vs. 75.3%, respectively; OR, 1.36; 95% CI, 0.84-2.20; I2 = 80%; low-quality evidence). However, based on a moderate certainty of evidence, VL outperformed DL in the subgroup analyses of intubation associated with difficult airways, inexperienced practitioners, or in-hospital settings. In the network meta-analysis comparing VL blade types, nonchanneled angular VL provided the best outcomes. The nonchanneled Macintosh video laryngoscope ranked second, and DL ranked third. Channeled VL was associated with the worst treatment outcomes. Discussion This pooled analysis found, with a low certainty of evidence, that VL does not improve intubation success relative to DL. Channeled VL had low efficacy in terms of intubation success compared with nonchanneled VL and DL. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=285702, identifier: CRD42021285702.
Collapse
Affiliation(s)
- Jae Guk Kim
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Chiwon Ahn
- Department of Emergency Medicine, College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | - Wonhee Kim
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Tae-Ho Lim
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Bo-Hyong Jang
- Department of Preventive Medicine, College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Youngsuk Cho
- Department of Emergency Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Hyungoo Shin
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Heekyung Lee
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Juncheol Lee
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Kyu-Sun Choi
- Department of Neurosurgery, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Min Kyun Na
- Department of Neurosurgery, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Sae Min Kwon
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea
| |
Collapse
|
3
|
Mazzoleni V, Padovani A, Morotti A. Emergency management of intracerebral hemorrhage. J Crit Care 2023; 74:154232. [PMID: 36565647 DOI: 10.1016/j.jcrc.2022.154232] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 12/06/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022]
Abstract
Acute intracerebral hemorrhage is a medical emergency with high mortality and morbidity. Neuroimaging has a fundamental role in the etiological diagnosis, patients monitoring and in the risk stratification of hematoma expansion and poor outcome. The cornerstones of medical treatment in the acute phase are blood pressure lowering and coagulopathy reversal. Prevention of hematoma expansion is the main goal of these therapies and their efficacy is strongly time-dependent with a narrow time window. This review provides an update on the etiological diagnostic workup, acute treatment and prognosis of intracerebral hemorrhage.
Collapse
Affiliation(s)
- Valentina Mazzoleni
- Department of Clinical and Experimental Sciences, Neurology Unit, University of Brescia, Brescia, Italy.
| | - Alessandro Padovani
- Department of Clinical and Experimental Sciences, Neurology Unit, University of Brescia, Brescia, Italy; Department of Neurological Sciences and Vision, Neurology Unit, ASST-Spedali Civili, Brescia, Italy
| | - Andrea Morotti
- Department of Neurological Sciences and Vision, Neurology Unit, ASST-Spedali Civili, Brescia, Italy
| |
Collapse
|
4
|
Salasky VR, Chang WTW. Neurotrauma Update. Emerg Med Clin North Am 2023; 41:19-33. [DOI: 10.1016/j.emc.2022.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
5
|
Hyland SJ, Pandya PA, Mei CJ, Yehsakul DC. Sugammadex to Facilitate Neurologic Assessment in Severely Brain-Injured Patients: Retrospective Analysis and Practical Guidance. Cureus 2022; 14:e30466. [DOI: 10.7759/cureus.30466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2022] [Indexed: 11/07/2022] Open
|
6
|
Lui A, Kumar KK, Grant GA. Management of Severe Traumatic Brain Injury in Pediatric Patients. FRONTIERS IN TOXICOLOGY 2022; 4:910972. [PMID: 35812167 PMCID: PMC9263560 DOI: 10.3389/ftox.2022.910972] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 05/10/2022] [Indexed: 11/23/2022] Open
Abstract
The optimal management of severe traumatic brain injury (TBI) in the pediatric population has not been well studied. There are a limited number of research articles studying the management of TBI in children. Given the prevalence of severe TBI in the pediatric population, it is crucial to develop a reference TBI management plan for this vulnerable population. In this review, we seek to delineate the differences between severe TBI management in adults and children. Additionally, we also discuss the known molecular pathogenesis of TBI. A better understanding of the pathophysiology of TBI will inform clinical management and development of therapeutics. Finally, we propose a clinical algorithm for the management and treatment of severe TBI in children using published data.
Collapse
Affiliation(s)
- Austin Lui
- Touro University College of Osteopathic Medicine, Vallejo, CA, United States
| | - Kevin K. Kumar
- Department of Neurosurgery, Stanford University, Stanford, CA, United States
- Division of Pediatric Neurosurgery, Lucile Packard Children’s Hospital, Palo Alto, CA, United States
| | - Gerald A. Grant
- Department of Neurosurgery, Stanford University, Stanford, CA, United States
- Division of Pediatric Neurosurgery, Lucile Packard Children’s Hospital, Palo Alto, CA, United States
- Department of Neurosurgery, Duke University, Durham, NC, United States
- *Correspondence: Gerald A. Grant,
| |
Collapse
|
7
|
Wen J, Chen J, Chang J, Wei J. Pulmonary complications and respiratory management in neurocritical care: a narrative review. Chin Med J (Engl) 2022; 135:779-789. [PMID: 35671179 PMCID: PMC9276382 DOI: 10.1097/cm9.0000000000001930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Indexed: 11/25/2022] Open
Abstract
ABSTRACT Neurocritical care (NCC) is not only generally guided by principles of general intensive care, but also directed by specific goals and methods. This review summarizes the common pulmonary diseases and pathophysiology affecting NCC patients and the progress made in strategies of respiratory support in NCC. This review highlights the possible interactions and pathways that have been revealed between neurological injuries and respiratory diseases, including the catecholamine pathway, systemic inflammatory reactions, adrenergic hypersensitivity, and dopaminergic signaling. Pulmonary complications of neurocritical patients include pneumonia, neurological pulmonary edema, and respiratory distress. Specific aspects of respiratory management include prioritizing the protection of the brain, and the goal of respiratory management is to avoid inappropriate blood gas composition levels and intracranial hypertension. Compared with the traditional mode of protective mechanical ventilation with low tidal volume (Vt), high positive end-expiratory pressure (PEEP), and recruitment maneuvers, low PEEP might yield a potential benefit in closing and protecting the lung tissue. Multimodal neuromonitoring can ensure the safety of respiratory maneuvers in clinical and scientific practice. Future studies are required to develop guidelines for respiratory management in NCC.
Collapse
Affiliation(s)
- Junxian Wen
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Dongcheng District, Beijing 100730, China
| | | | | | | |
Collapse
|
8
|
Arbour R. Nursing Guidelines for Sedation Titration or Pausing to Facilitate Neurological Assessment. Crit Care Nurse 2022; 42:79-81. [PMID: 35100625 DOI: 10.4037/ccn2022761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Richard Arbour
- Richard Arbour is a critical care clinical nurse specialist in the Temple University Health System, Philadelphia, Pennsylvania
| |
Collapse
|
9
|
El-Swaify ST, Refaat MA, Ali SH, Abdelrazek AEM, Beshay PW, Kamel M, Bahaa B, Amir A, Basha AK. Controversies and evidence gaps in the early management of severe traumatic brain injury: back to the ABCs. Trauma Surg Acute Care Open 2022; 7:e000859. [PMID: 35071780 PMCID: PMC8734008 DOI: 10.1136/tsaco-2021-000859] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 12/10/2021] [Indexed: 11/04/2022] Open
Abstract
Traumatic brain injury (TBI) accounts for around 30% of all trauma-related deaths. Over the past 40 years, TBI has remained a major cause of mortality after trauma. The primary injury caused by the injurious mechanical force leads to irreversible damage to brain tissue. The potentially preventable secondary injury can be accentuated by addressing systemic insults. Early recognition and prompt intervention are integral to achieve better outcomes. Consequently, surgeons still need to be aware of the basic yet integral emergency management strategies for severe TBI (sTBI). In this narrative review, we outlined some of the controversies in the early care of sTBI that have not been settled by the publication of the Brain Trauma Foundation’s 4th edition guidelines in 2017. The topics covered included the following: mode of prehospital transport, maintaining airway patency while securing the cervical spine, achieving adequate ventilation, and optimizing circulatory physiology. We discuss fluid resuscitation and blood product transfusion as components of improving circulatory mechanics and oxygen delivery to injured brain tissue. An outline of evidence-based antiplatelet and anticoagulant reversal strategies is discussed in the review. In addition, the current evidence as well as the evidence gaps for using tranexamic acid in sTBI are briefly reviewed. A brief note on the controversial emergency surgical interventions for sTBI is included. Clinicians should be aware of the latest evidence for sTBI. Periods between different editions of guidelines can have an abundance of new literature that can influence patient care. The recent advances included in this review should be considered both for formulating future guidelines for the management of sTBI and for designing future clinical studies in domains with clinical equipoise.
Collapse
Affiliation(s)
| | - Mazen A Refaat
- Department of surgery, Ain Shams University Hospital, Cairo, Egypt
| | - Sara H Ali
- Department of surgery, Ain Shams University Hospital, Cairo, Egypt
| | | | | | - Menna Kamel
- Department of surgery, Ain Shams University Hospital, Cairo, Egypt
| | - Bassem Bahaa
- Department of surgery, Ain Shams University Hospital, Cairo, Egypt
| | - Abdelrahman Amir
- Department of surgery, Ain Shams University Hospital, Cairo, Egypt
| | - Ahmed Kamel Basha
- Department of neurosurgery, Ain Shams University Faculty of Medicine, Cairo, Egypt
| |
Collapse
|
10
|
Cai G, Ru W, Xu Q, Wu J, Gong S, Yan J, Shen Y. Association Between Oxygen Partial Pressure Trajectories and Short-Term Outcomes in Patients With Hemorrhagic Brain Injury. Front Med (Lausanne) 2021; 8:681200. [PMID: 34568355 PMCID: PMC8458649 DOI: 10.3389/fmed.2021.681200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 08/10/2021] [Indexed: 11/29/2022] Open
Abstract
Objectives: Arterial hyperoxia is reportedly a risk factor for poor outcomes in patients with hemorrhagic brain injury (HBI). However, most previous studies have only evaluated the effects of hyperoxia using static oxygen partial pressure (PaO2) values. This study aimed to investigate the association between overall dynamic oxygenation status and HBI outcomes, using longitudinal PaO2 data. Methods: Data were extracted from the Medical Information Mart for Intensive Care III database. Longitudinal PaO2 data obtained within 72 h of admission to an intensive care unit were analyzed, using a group-based trajectory approach. In-hospital mortality was used as the primary outcomes. Multivariable logistic models were used to explore the association between PaO2 trajectory and outcomes. Results: Data of 2,028 patients with HBI were analyzed. Three PaO2 trajectory types were identified: Traj-1 (mild hyperoxia), Traj-2 (transient severe hyperoxia), and Traj-3 (persistent severe hyperoxia). The initial and maximum PaO2 of patients with Traj-2 and Traj-3 were similar and significantly higher than those of patients with Traj-1. However, PaO2 in patients with Traj-2 decreased more rapidly than in patients with Traj-3. The crude in-hospital mortality was the lowest for patients with Traj-1 and highest for patients with Traj-3 (365/1,303, 209/640, and 43/85 for Traj-1, Traj-2, and Traj-3, respectively; p < 0.001), and the mean Glasgow Coma Scale score at discharge (GCSdis) was highest for patients with Traj-1 and lowest in patients with Traj-3 (13 [7–15], 11 [6–15], and 7 [3–14] for Traj-1, Traj-2, and Traj-3, respectively; p < 0.001). The multivariable model revealed that the risk of death was higher in patients with Traj-3 than in patients with Traj-1 (odds ratio [OR]: 3.3, 95% confidence interval [CI]: 1.9–5.8) but similar for patients with Traj-1 and Traj-2. Similarly, the logistic analysis indicated the worst neurological outcomes in patients with Traj-3 (OR: 3.6, 95% CI: 2.0–6.4, relative to Traj-1), but similar neurological outcomes for patients in Traj-1 and Traj-2. Conclusion: Persistent, but not transient severe arterial hyperoxia, was associated with poor outcome in patients with HBI.
Collapse
Affiliation(s)
- Guolong Cai
- Department of Intensive Care, Zhejiang Hospital, Hangzhou, China
| | - Weizhe Ru
- Department of Oncology, Cixi People's Hospital, Cixi, China
| | - Qianghong Xu
- Department of Intensive Care, Zhejiang Hospital, Hangzhou, China
| | - Jiong Wu
- Department of Neurology, Zhejiang Hospital, Hangzhou, China
| | - Shijin Gong
- Department of Intensive Care, Zhejiang Hospital, Hangzhou, China
| | - Jing Yan
- Department of Intensive Care, Zhejiang Hospital, Hangzhou, China
| | - Yanfei Shen
- Department of Intensive Care, Zhejiang Hospital, Hangzhou, China
| |
Collapse
|
11
|
Mroz EL, Olasoji E, Henke C, Lim C, Pacheco SC, Swords G, Hester J, Weisbrod N, Babi MA, Busl K, Baron-Lee J. Applying the Care and Communication Bundle to Promote Palliative Care in a Neuro-Intensive Care Unit: Why and How. J Palliat Med 2021; 24:1849-1857. [PMID: 34191600 DOI: 10.1089/jpm.2020.0730] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Delivery of palliative care in neurointensive care units (neuro-ICUs) can be inconsistent, often due to absence of formal care triggers. The Care and Communication Bundle (CCB) of Quality Indicators provides a standardized process to deliver effective palliative care services in ICUs, but application of these indicators in this setting has not yet been systemically assessed. Objectives: To evaluate the fit of a CCB in the neuro-ICU through a novel scoring system and identify barriers to adherence. Design: CCB standards for a neuro-ICU were delineated. Assessment of documented indicators and barriers was conducted through electronic medical record retrospective review. Setting/Subjects: A 30-bed neuro-ICU in a large Academic Medical Center in the Southeastern United States. Chart reviews were conducted for 133 critically ill neurology and neurosurgery patients who expired between November 2018 and January 2020. Results: Results demonstrate moderate adherence to CCB standards, including excellent consistency in establishment of patient-centered communication and referral to supportive services (e.g., social work, spiritual support). Identified areas for improvement include documentation of patient and family involvement in care process (i.e., advance directive completion, interdisciplinary team meetings). Conclusions: Application of the CCB in the neuro-ICU is useful for examining adherence to time-based triggers of palliative care standards. The novel scoring system offers opportunities to motivate improvement and reduce variation in palliative care integration.
Collapse
Affiliation(s)
- Emily L Mroz
- Department of Psychology, University of Florida, Gainesville, Florida, USA.,Department of Neurology, University of Florida, Gainesville, Florida, USA
| | - Esther Olasoji
- Department of Neurology, University of Florida, Gainesville, Florida, USA
| | - Charlotte Henke
- Department of Neurology, University of Florida, Gainesville, Florida, USA
| | - Christina Lim
- Department of Neurology, University of Florida, Gainesville, Florida, USA
| | - Sean C Pacheco
- Department of Neurology, University of Florida, Gainesville, Florida, USA
| | - Gabriel Swords
- Department of Neurology, University of Florida, Gainesville, Florida, USA
| | - Jeannette Hester
- Neuromedicine Intensive Care Unit, Department of Nursing and Patient Services, UF Health Shands Hospital, Gainesville, Florida, USA
| | - Neal Weisbrod
- Department of Neurology, University of Florida, Gainesville, Florida, USA
| | - Marc A Babi
- Department of Neurology, University of Florida, Gainesville, Florida, USA
| | - Katharina Busl
- Department of Neurology, University of Florida, Gainesville, Florida, USA
| | | |
Collapse
|
12
|
Ramineni A, Roberts EA, Vora M, Mahboobi SK, Nozari A. Anesthesia Considerations in Neurological Emergencies. Neurol Clin 2021; 39:319-332. [PMID: 33896521 DOI: 10.1016/j.ncl.2021.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Airway obstruction and respiratory failure are common complications of neurological emergencies. Anesthesia is often employed for airway management, surgical and endovascular interventions or in the intensive care units in patients with altered mental status or those requiring burst suppression. This article provides a summary of the unique airway management and anesthesia considerations and controversies for neurologic emergencies in general, as well as for specific commonly encountered conditions: elevated intracranial pressure, neuromuscular respiratory failure, acute ischemic stroke, and acute cervical spinal cord injury.
Collapse
Affiliation(s)
- Anil Ramineni
- Department of Neurology, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA 01805, USA
| | - Erik A Roberts
- Boston University School of Medicine, 72 East Concord Street, Boston, MA 02118, USA
| | - Molly Vora
- Boston University School of Medicine, 72 East Concord Street, Boston, MA 02118, USA
| | - Sohail K Mahboobi
- Department of Anesthesiology, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA 01805, USA; Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA 02111, USA
| | - Ala Nozari
- Boston University School of Medicine, 72 East Concord Street, Boston, MA 02118, USA; Department of Anesthesiology, Boston Medical Center, 750 Albany Street, Power Plant 2R, Boston, MA 02118, USA.
| |
Collapse
|
13
|
Prabhakar H, Tripathy S, Gupta N, Singhal V, Mahajan C, Kapoor I, Wanchoo J, Kalaivani M. Consensus Statement on Analgo-sedation in Neurocritical Care and Review of Literature. Indian J Crit Care Med 2021; 25:126-133. [PMID: 33707888 PMCID: PMC7922463 DOI: 10.5005/jp-journals-10071-23712] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aim and objective Our main objective in developing this consensus is to bring together a set of most agreed-upon statements from a panel of global experts that would act as a guide for clinicians working in neurocritical care units (NCCUs). Background Given the physiological benefits of analgo-sedation in the NCCU, there is little information on their tailoring in the NCCU. This lack of evidence and guidelines on the use of sedation and analgesia in patients with neurological injury leads to a variation in clinical care based on patient requirements and institutional protocols. Review results Thirty-nine international experts agreed to be a member of this consensus panel. A Delphi method based on a Web-based questionnaire developed with Google Forms on a secure institute server was used to seek opinions of experts. Questions were related to sedation and analgesia in the neurocritical care unit. A predefined threshold of agreement was established as 70% to support any recommendation, strong, moderate, or weak. No recommendations were made below this threshold. Responses were collected from all the experts, summated, and expressed as percentage (%). After three rounds, consensus could be reached for 6 statements related to analgesia and 5 statements related to sedation. Consensus could not be reached for 10 statements related to analgesia and 5 statements related to sedation. Conclusion This global consensus statement may help in guiding practitioners in clinical decision-making regarding analgo-sedation in the NCCUs, thereby helping in improving patient recovery profiles. Clinical significance In the lack of high-level evidence, the recommendations may be seen as the current best clinical practice. How to cite this article Prabhakar H, Tripathy S, Gupta N, Singhal V, Mahajan C, Kapoor I, et al. Consensus Statement on Analgo-sedation in Neurocritical Care and Review of Literature. Indian J Crit Care Med 2021;25(2):126–133.
Collapse
Affiliation(s)
- Hemanshu Prabhakar
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Swagata Tripathy
- Department of Anaesthesia, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Nidhi Gupta
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Vasudha Singhal
- Department of Neuroanaesthesiology and Critical Care, Medanta: The Medicity, Gurugram, Haryana, India
| | - Charu Mahajan
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Indu Kapoor
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Jaya Wanchoo
- Department of Neuroanaesthesiology and Critical Care, Medanta: The Medicity, Gurugram, Haryana, India
| | - Mani Kalaivani
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
14
|
Berlit P, Bösel J, Gahn G, Isenmann S, Meuth SG, Nolte CH, Pawlitzki M, Rosenow F, Schoser B, Thomalla G, Hummel T. "Neurological manifestations of COVID-19" - guideline of the German society of neurology. Neurol Res Pract 2020; 2:51. [PMID: 33283160 PMCID: PMC7708894 DOI: 10.1186/s42466-020-00097-7] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 11/17/2020] [Indexed: 12/28/2022] Open
Abstract
Infection with the new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) leads to a previously unknown clinical picture, which is known as COVID-19 (COrona VIrus Disease-2019) and was first described in the Hubei region of China. The SARS-CoV-2 pandemic has implications for all areas of medicine. It directly and indirectly affects the care of neurological diseases. SARS-CoV-2 infection may be associated with an increased incidence of neurological manifestations such as encephalopathy and encephalomyelitis, ischemic stroke and intracerebral hemorrhage, anosmia and neuromuscular diseases. In October 2020, the German Society of Neurology (DGN, Deutsche Gesellschaft für Neurologie) published the first guideline on the neurological manifestations of the new infection. This S1 guideline provides guidance for the care of patients with SARS-CoV-2 infection regarding neurological manifestations, patients with neurological disease with and without SARS-CoV-2 infection, and for the protection of healthcare workers. This is an abbreviated version of the guideline issued by the German Neurological society and published in the Guideline repository of the AWMF (Working Group of Scientific Medical Societies; Arbeitsgemeinschaft wissenschaftlicher Medizinischer Fachgesellschaften).
Collapse
Affiliation(s)
- Peter Berlit
- Secretary General of the German Society of Neurology, Berlin, Germany
| | - Julian Bösel
- Department of Neurology, Klinikum Kassel, DGNI, Kassel, Germany
| | - Georg Gahn
- Department of Neurology, Klinikum Karlsruhe, DGNI, Karlsruhe, Germany
| | - Stefan Isenmann
- Department of Neurology and Clinical Neurophysiology, St. Josef Hospital Moers, Moers, Germany
| | - Sven G. Meuth
- Department of Neurology, University Hospital Düsseldorf, Düsseldorf,, Germany
| | - Christian H. Nolte
- Department of Neurology with Experimental Neurology and Center for Stroke Research Berlin (CSB) Charité-University Berlin, Berlin, Germany
| | - Marc Pawlitzki
- Department of Neurology with Institute for Translational Neurology, University Hospital Münster, Münster, Germany
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhein-Main, Center of Neurology and Neurosurgery, University Hospital Frankfurt, Frankfurt, Germany
| | - Benedikt Schoser
- Friedrich Baur Institute at the Neurological Department, LM-University Munich, Munich, Germany
| | - Götz Thomalla
- Department of Neurology, Head and Neurocenter, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Hummel
- Interdisciplinary Center for Smelling and Tasting, University ENT Hospital Dresden, German Society for ENT Medicine, Dresden, Germany
| |
Collapse
|
15
|
S1-Leitlinie: Neurologische Manifestationen bei COVID-19. DGNEUROLOGIE 2020. [PMCID: PMC7550844 DOI: 10.1007/s42451-020-00254-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
|
16
|
Sauter TC, Rönz K, Hirschi T, Lehmann B, Hütt C, Exadaktylos AK, Müller M. Intubation in acute alcohol intoxications at the emergency department. Scand J Trauma Resusc Emerg Med 2020; 28:11. [PMID: 32041639 PMCID: PMC7011261 DOI: 10.1186/s13049-020-0707-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 02/05/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Guidelines recommend endotracheal intubation in trauma patients with a Glasgow coma scale (GCS) < 9 because of the loss of airway reflexes and consequential risk of airway obstruction. However, in patients with acute alcohol intoxication guidelines are not clear. Thus, we aimed to determine the proportional incidence of intubation in alcohol intoxication and compare the clinical characteristics of intubated and non-intubated patients, as well as reasons for intubation in all patients and in the subgroup of patients with reduced GCS (< 9) but without traumatic brain injury. METHODS We performed a retrospective analysis of all consultations to an urban ED in Switzerland that presented with an acute alcohol intoxication between 1st June 2012 and 31th Mai 2017. Patient and emergency consultations' characteristics, related injuries, intubation and reason for intubations were extracted. As a subgroup analysis, we analysed the patients with a GCS < 9 without a traumatic brain injury. RESULTS Of 3003 consultations included from 01.06.2012 to 31.05.2017, 68 were intubated, leading to a proportional incidence of 2.3% intubations in alcohol-intoxication. Intubated patients had a lower blood alcohol concentration (1.3 g/kg [IQR 1.0-2.2] vs. 1.6 g/kg [IQR1.1-2.2], p = 0.034) and less often suffered from chronic alcohol abuse (1183 [39.4%] patients vs. 14 [20.6%], p = 0.001) than non-intubated patients. Patients with trauma were intubated more often (33 patients [48.5%] vs. 742 [25.3%], p < 0.001). In subgroup analysis, 110/145 patients (74.3%) were not intubated; again, more intubated patients had a history of trauma (9 patients [25.7%] vs. 10 [9.1%], p = 0.011). CONCLUSIONS Intubation in alcohol-intoxicated patients is rare and, among intoxicated patients with GCS < 9, more than two thirds were not intubated in our study - without severe complications. Trauma in general, independent of the history of a traumatic brain injury, and a missing history of chronic alcohol abuse are associated with intubation, but not with blood alcohol concentration. Special caution is required for intoxicated patients with trauma or other additional intoxications or diseases.
Collapse
Affiliation(s)
- Thomas C Sauter
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland. .,Medical Skills Lab, Charité Medical School Berlin, Berlin, Germany.
| | - Katharina Rönz
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland.,Department of Anaesthesiology, Hôpital Cantonal Fribourg, Fribourg, Switzerland
| | - Trevor Hirschi
- Department of Anaesthesiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Beat Lehmann
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland
| | - Christopher Hütt
- Department of Anaesthesiology and Intensive Care, University Hospital Bonn, Bonn, Germany
| | - Aristomenis K Exadaktylos
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland
| | - Martin Müller
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland.,Department of Anaesthesiology and Intensive Care, University Hospital Bonn, Bonn, Germany
| |
Collapse
|
17
|
Robba C, Bonatti G, Battaglini D, Rocco PRM, Pelosi P. Mechanical ventilation in patients with acute ischaemic stroke: from pathophysiology to clinical practice. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:388. [PMID: 31791375 PMCID: PMC6889568 DOI: 10.1186/s13054-019-2662-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 10/25/2019] [Indexed: 12/17/2022]
Abstract
Most patients with ischaemic stroke are managed on the ward or in specialty stroke units, but a significant number requires higher-acuity care and, consequently, admission to the intensive care unit. Mechanical ventilation is frequently performed in these patients due to swallowing dysfunction and airway or respiratory system compromise. Experimental studies have focused on stroke-induced immunosuppression and brain-lung crosstalk, leading to increased pulmonary damage and inflammation, as well as reduced alveolar macrophage phagocytic capability, which may increase the risk of infection. Pulmonary complications, such as respiratory failure, pneumonia, pleural effusions, acute respiratory distress syndrome, lung oedema, and pulmonary embolism from venous thromboembolism, are common and found to be among the major causes of death in this group of patients. Furthermore, over the past two decades, tracheostomy use has increased among stroke patients, who can have unique indications for this procedure—depending on the location and type of stroke—when compared to the general population. However, the optimal mechanical ventilator strategy remains unclear in this population. Although a high tidal volume (VT) strategy has been used for many years, the latest evidence suggests that a protective ventilatory strategy (VT = 6–8 mL/kg predicted body weight, positive end-expiratory pressure and rescue recruitment manoeuvres) may also have a role in brain-damaged patients, including those with stroke. The aim of this narrative review is to explore the pathophysiology of brain-lung interactions after acute ischaemic stroke and the management of mechanical ventilation in these patients.
Collapse
Affiliation(s)
- Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, University of Genoa, Largo Rosanna Benzi, 15, 16100, Genoa, Italy.
| | - Giulia Bonatti
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, University of Genoa, Largo Rosanna Benzi, 15, 16100, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Denise Battaglini
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, University of Genoa, Largo Rosanna Benzi, 15, 16100, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, University of Genoa, Largo Rosanna Benzi, 15, 16100, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| |
Collapse
|
18
|
Buckley CT, Dickerson RN. Propofol: A Risk Factor for Caloric Overfeeding and Inadequate Protein Delivery. Hosp Pharm 2019; 55:151-152. [PMID: 32508350 DOI: 10.1177/0018578719888908] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Roland N Dickerson
- The University of Tennessee Health Science Center College of Pharmacy, Memphis, TN, USA
| |
Collapse
|
19
|
Abstract
Subarachnoid hemorrhage is an often devastating intracranial hemorrhage resulting from acute bleeding into the subarachnoid space. Although its overall incidence is less than that of acute ischemic stroke, sub-arachnoid hemorrhage carries increased risks of both mortality and disability. Although many patients with subarachnoid hemorrhage are transferred to specialty centers, they might initially present to small community-based hospitals. Treatment for these patients is complex, requiring specialized care and knowledge, and various complications can occur quickly and without warning. Therefore, all members of the health care team who care for these patients must understand proper management. Nurses in the intensive care unit play an important role in influencing outcomes, as they are best positioned to recognize neurological decline and provide rapid intervention. This article discusses the anatomy relevant to, and the epidemiology and pathophysiology of, subarachnoid hemorrhage and provides an overview of current evidence and clinical guidelines for managing this brain injury.
Collapse
Affiliation(s)
- Bryan Boling
- Bryan Boling is an advanced practice provider, Department of Anesthesiology, Division of Critical Care, University of Kentucky, Lexington, Kentucky. Tasha R. Groves is an advanced practice provider, Department of Anesthesiology, Division of Critical Care, University of Kentucky
| | - Tasha R. Groves
- Bryan Boling is an advanced practice provider, Department of Anesthesiology, Division of Critical Care, University of Kentucky, Lexington, Kentucky. Tasha R. Groves is an advanced practice provider, Department of Anesthesiology, Division of Critical Care, University of Kentucky
| |
Collapse
|
20
|
Diestro JDB, Dorotan MKC, Andal VMD, Tomas AB, Geocadin RG, Collantes MEV. Ischaemic stroke in a patient with myasthaenic crisis and antiphospholipid antibody syndrome. BMJ Case Rep 2019; 12:12/8/e231239. [PMID: 31466961 DOI: 10.1136/bcr-2019-231239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
While autoimmune diseases have been frequently found to coexist in the same patients, the co-occurrence of myasthaeniagravis and antiphospholipid antibody syndrome (APAS) has only been reported in eight cases. We present a case of a 46-year-old Filipina who developed ischaemic stroke while admitted at the neurocritical unit for myasthaenic crisis. She was successfully thrombolysed with intravenous recombinant tissue plasminogen activator (rTPA), given a regimen of intravenous Ig and a dose of cyclophosphamide prior to discharge. Extensive workup revealed APAS to be the aetiology of her stroke. Twenty-one months into her follow-up, she is doing well with a modified Rankin Score of 0. Our case suggests that rTPA followed by immunomodulators may be given safely in myasthaenic crisis patients who develop ischaemic stroke. We emphasise the importance of doing a comprehensive neurological evaluation in agitated patients in the critical care unit.
Collapse
Affiliation(s)
- Jose Danilo B Diestro
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Maria Kristina C Dorotan
- Department of Neurology, Lewis Katz School ofMedicine, Temple University, Philadelphia, Pennsylvania, USA
| | - Vida Margarette D Andal
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Arnolfo B Tomas
- Department of Medicine, College of Medicine and Philippines General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Romergryko G Geocadin
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ma Epifania V Collantes
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| |
Collapse
|
21
|
Corradi F, Robba C, Tavazzi G, Via G. Combined lung and brain ultrasonography for an individualized "brain-protective ventilation strategy" in neurocritical care patients with challenging ventilation needs. Crit Ultrasound J 2018; 10:24. [PMID: 30221312 PMCID: PMC6139291 DOI: 10.1186/s13089-018-0105-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 08/23/2018] [Indexed: 01/27/2023] Open
Abstract
When intracranial hypertension and severe lung damage coexist in the same clinical scenario, their management poses a difficult challenge, especially as concerns mechanical ventilation management. The needs of combined lung and brain protection from secondary damage may conflict, as ventilation strategies commonly used in patients with ARDS are potentially associated with an increased risk of intracranial hypertension. In particular, the use of positive end-expiratory pressure, recruitment maneuvers, prone positioning, and protective lung ventilation can have undesirable effects on cerebral physiology: they may positively or negatively affect intracranial pressure, based on the final repercussions on PaO2 and cerebral perfusion pressure (through changes in cardiac output, mean arterial pressure, venous return, PaO2 and PaCO2), also according to the baseline conditions of cerebral autoregulation. Lung ultrasound (LUS) and brain ultrasound (BUS, as a combination of optic nerve sheath diameter assessment and cerebrovascular Doppler ultrasound) have independently proven their potential in respectively monitoring lung aeration and brain physiology at the bedside. In this narrative review, we describe how the combined use of LUS and BUS on neurocritical patients with demanding mechanical ventilation needs can contribute to ventilation management, with the aim of a tailored "brain-protective ventilation strategy."
Collapse
Affiliation(s)
- Francesco Corradi
- Servizio di Anestesia e Rianimazione, Ente ospedaliero Ospedali Galliera, Genoa, Italy
| | - Chiara Robba
- Anaesthesia and Intensive Care, IRCSS S. Martino Hospital, Genoa, Italy.,Neurocritical Care Unit, Addenbrookes Hospital Cambridge, Cambridge, UK
| | - Guido Tavazzi
- Emergency Department, Anaesthesia and Intensive Care Unit, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy.,Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, Anaesthesia, Intensive Care and Pain Therapy Unit, University of Pavia, Pavia, Italy
| | - Gabriele Via
- Cardiac Anesthesia and Intensive Care, Cardiocentro Ticino, Via Tesserete, 48, Lugano, Switzerland.
| |
Collapse
|
22
|
Abstract
PURPOSE OF REVIEW Subdural hematomas (SDH) represent common neurosurgical problem associated with significant morbidity, mortality, and high recurrence rates. SDH incidence increases with age; numbers of patients affected by SDH continue to rise with our aging population and increasing number of people taking antiplatelet agents or anticoagulation. Medical and surgical SDH management remains a subject of investigation. RECENT FINDINGS Initial management of patients with concern for altered mental status with or without trauma starts with Emergency Neurological Life Support (ENLS) guidelines, with a focus on maintaining ICP < 22 mmHg, CPP > 60 mmHg, MAP 80-110 mmHg, and PaO2 > 60 mmHg, followed by rapid sequence intubation if necessary, and expedited acquisition of imaging to identify a space-occupying lesion. Patients are administered anti-seizure medications, and their antiplatelet medications or anticoagulation may be reversed if neurosurgical interventions are anticipated, or until hemorrhage is stabilized on imaging. Medical SDH care focuses on (a) management of intracranial hypertension; (b) maintenance of adequate cerebral perfusion; (c) seizure prevention and treatment; (d) maintenance of normothermia, eucarbia, euglycemia, and euvolemia; and (e) early initiation of enteral feeding, mobilization, and physical therapy. Post-operatively, SDH patients require ICU level care and are co-managed by neurointensivists with expertise in treating increased intracranial pressure, seizures, and status epilepticus, as well as medical complications of critical illness. Here, we review various aspects of medical management with a brief overview of pertinent literature and clinical trials for patients diagnosed with SDH.
Collapse
|